Out of control anger

As many as 5 percent of people suffer from a disorder that can ruin their lives

By Carey Goldberg, Globe Staff | August 8, 2005

They used to just call it a bad temper and tell you to count to 10. Then came bunches of guys sitting around in circles and learning ''anger management."

Now, increasingly, the catchphrase is ''Intermittent Explosive Disorder." Researchers delving into pathological anger report that it is more widespread than anyone had suspected. And that their understanding of its biological roots is deepening, raising prospects of better treatment.

''It's not simply bad behavior," said Emil Coccaro of the University of Chicago, a leading anger researcher. ''There's a biology and a psychology and a genetics and a neuroscience behind this, and you can come up with strategies for intervention just like for anything else, like diabetes or hypertension or depression."

For all the buzz about phenomena like hockey dads and the recent road rage incidents, it was only this summer that researchers got definitive data on how common such volatility is.

A national study found that at some point in their lives, about 5 percent of people have such frequent, serious blow-ups that they qualify as suffering from Intermittent Explosive Disorder, a full-fledged psychiatric diagnosis. It is twice as common in men as in women and tends to begin before age 20.

The numbers translate into many millions of circles of trembling misery and anxiety. Wives live in fear of their otherwise sweet husbands' next tirade, and wonder if they dare bring children into such a violent world of wrath.

Husbands find that sometimes, the smallest provocation of their wives brings on a firestorm. Parents struggle to understand why a son puts his fist through things, kicks pets, or screams at siblings. Is this a character issue? Or a medical problem?

Specialists say that their growing knowledge does not excuse such explosions, but it can help explain them. A picture has begun to emerge of what happens in the rage-prone brain, and a central culprit appears to be the chemical messenger that newer anti-depressants have made a household word: serotonin.

In broad terms, serotonin -- active in the frontal, ''thinking" part of the brain -- is needed when a person stops a bad impulse. When someone is low on serotonin, that brake can get weak.

Brain structure may also play a role. ''In people with impulsive aggression, there's more chaos in the front part of the brain," said Dr. Jon Grant, an associate professor of psychiatry at the University of Minnesota in Minneapolis.

So some of the problem may lie in the very formations of the nerves, suggesting that genes or development may be at fault. Childhood abuse is also common in people with the disorder, suggesting that environment, too, plays an important role.

It gets even more complicated. Other brain chemicals are involved -- perhaps some that influence the ''gas" rather than the ''brake." And studies have found psychological differences in the anger-prone, compared with others. Tests show that they are likelier to believe other people have hostile intentions, for example.

Despite such insights, specialists readily acknowledge that biologically, impulsive anger -- like so much in the brain -- remains largely a mystery. But in recent years they have begun to use educated guesses to try a wide array of drugs to fight it.

None of the drugs has federal approval specifically for Intermittent Explosive Disorder, but doctors and researchers have been prescribing them ''off-label," and report that they can often help, though not always and not everyone.

Anti-depressants of the Prozac generation sometimes bring results, they say; so do mood stabilizers, and drugs that were used initially to stop seizures.

A major, federally funded study published last month in the American Journal of Psychiatry found that among autistic children, risperidone, a newer anti-psychotic drug, could reduce violent outbursts for up to six months with few side effects. Risperidone has prominent effects on serotonin, so the study's positive results underscore the importance of serotonin in impulsive aggression, said its lead author, Dr. James McCracken.

Therapy helps as well, specialists say. When well-run, anger management groups can prove effective, they say, and so does individual therapy that helps patients recognize their problematic reactions and find ways to defuse themselves.Treatment can involve training in relaxation, habits of thought (like thinking, ''Maybe he wasn't trying to make you mad"), and coping skills like walking away when things start to get hot.

''Between both medication and therapy, I'd say probably the majority of people can find some relief," Grant said. Once, anger problems tended to lead many straight to jail; now, ''We can offer people some real hope about what might allow them to get better control over this."

No miracle drug appears to be on its way, though. For now, researchers predict that they will be largely limited to clinical trials using existing drugs, because drug companies are unlikely to push hard for specific anti-rage agents.

For one thing, Coccaro pointed out, company lawyers are scared that if violent patients go onto a drug and then commit violence again, the company could be held liable.

There is a broader problem, too, he wrote in a recent journal editorial: People who explode are not very lovable. No celebrity is likely to volunteer to be a poster child for Intermittent Explosive Disorder. And philanthropists are less likely to contribute to research aimed at helping people viewed as perpetrators rather than patients or victims.

The patients themselves can be problematic as well, resisting treatment even when surrounded by wrecked lives.

''People say, 'I don't have an illness, I have an anger -- It's not I who have a problem, it's you," said Ronald Kessler of Harvard University, who led the national study on how common mental illnesses are. Often, he said, patients have already lost jobs and spouses before they seek help.

Some specialists say they also hope that now that it is clear how common impulse disorders are, they will get more attention, despite the obstacles, from researchers and grantmakers. Kessler's study found that when all the impulse disorders are lumped together, from compulsive gambling to Attention Deficit Disorder, they are even more common than mood problems like depression.

''The social implications are huge," said McCracken, a professor of psychiatry at the University of California at Los Angeles. Think, he said, of the impact of violence and compulsions like gambling, both on the perpetrators and people around them.

''I think a deeper understanding of these impulse disorders and better-identified treatment choices could have profound benefits for society," he said.

A June study estimated that roughly 1 in 20 people has had ''intermittent explosive disorder" -- a form of destructive, uncontrolled anger -- during their lifetime. The disorder, considered an impulse-control problem, is most common among 18-29 year-olds and its prevalence declines with age.